Provider Demographics
NPI:1508401779
Name:REYNOLDS, TAYLOR (RN)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 MARION PIKE STE 3
Mailing Address - Street 2:
Mailing Address - City:COAL GROVE
Mailing Address - State:OH
Mailing Address - Zip Code:45638-2958
Mailing Address - Country:US
Mailing Address - Phone:740-646-6640
Mailing Address - Fax:
Practice Address - Street 1:2903 S 5TH ST
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:OH
Practice Address - Zip Code:45638-2866
Practice Address - Country:US
Practice Address - Phone:740-646-6640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-12
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA173792101YA0400X
OHRN.535900163W00000X, 163WA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0378862Medicaid